The story of the lazy,
incompetent therapist who
always blamed her client.
Reflective supervision the treatment of borderline personality disorder
The program
• Dpsych program at Wollongong has a
specific focus on the treatment of
personality disorders and in particular
Borderline Personality Disorder.
• Interns complete a year long placement at
both the clinic and Specialist Psychologist
Services which is part of Area Health.
The program
• As part of the SPS placement they are
expected to co-lead a DBT group and
undertake client assessments for
suitability to the program.
• At the clinic they are expected to take up
to five personality disordered clients and
provide longer term treatment (32 to 50
sessions).
The program
• Delivered utilising a psychodynamic
approach either objects relations or
schema therapy focus.
• Supervision is provided individually by
myself one hour a week plus extras
during emergencies
The therapists and their issues
• Students have not had their own therapy, have
not worked in this model and are sitting down to
work with the more complex end of the
personality disorder spectrum.
• They have a feeling of moderate competence in
CBT but often feel quite deskilled as they are
moving to a totally different model.
The therapists and their issues
• They carry fantasies (negative) of the type of
client they are going to work with that are often
quite unrealistic. This combines with an over
idealised idea of what a good therapist should
be to create considerable anxiety.
• On the positive side they come to this with
enormous talent and intelligence and a positive
if somewhat idealised picture of the experience.
The clients and their impact
• The capacity for BPD to evoke powerful
negative and positive emotions in
therapists along with at time
uncontrollable emotions is well known.
• The term projective identification seems
tailored made to describe this reaction.
Although it is often more experienced like
a projectile.
The clients and their impact
• It is not like this is just a temporary state
of affairs. For the most part it is a roller
coaster for most of the time.
The clients and their impact
There is a range of intense feelings evoked:
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Frustration and rage
Guilt and resentment
Anger and sadism
Fear and avoidance
Pity
Disgust
Helplessness and hopelessness
Despair
Feelings omnipotence and power
Protectiveness
The clients and their impact
• ….and that can be in just one session
The treatment and its techniques
• Because BPD is a disorder of relationship
then this becomes the central focus in
therapy.
• There is a semi-constant need to rework
the working alliance back to a positive
position over and over again and to
rebuild a sense of safety in the room (for
both client and therapist).
The treatment and its techniques
• To do this the therapist needs to come
back to a position of empathy for the
client no matter what is projected onto the
therapist in terms of idealised or negative
emotions. Without this the working
alliance cannot be maintained.
The treatment and its techniques
• Looking at the recent overviews of all the
effective therapies for BPD Fonagy comes
to the conclusion that they all have a
central theme of building a reflective
space within the client
The treatment and its techniques
• Call it what you will, wise mind,
integration of internal objects, reparenting at the end of the day we are
looking to develop an internal space
where the client can consider their
feelings and their needs and make more
useful choices about meeting those needs.
• A place where the client can be more in
touch with their humanness.
The treatment and its techniques
• The focus of supervision is on
development of technique.
• This is at the expense of theory and
deliberately so. Theory is intellectual and
the basic techniques are to some degree
theory neutral. (Wallerstein 1990 Abrams
et al 1989).
• Even more, new interns to this model can
only absorb so much.
The treatment and its techniques
• Far more important they are able to focus
on the relationship and development of
an empathic and neutral stance towards
the client.
• They can fit all this into their theoretical
model later on.
• There are strong counter arguments to
this approach as well. Rangell 1988
The treatment and its techniques
• A simplistic model is presented aka
Scheslinger of “doing family therapy
inside the clients head”. To do good
family therapy then all family members
need to be in the room.
• The need to give different aspect of the
self a voice
The treatment and its techniques
• Concept of always refocusing inside an
individual. Take the outside in. In other
words external interactions, relationships
and conflicts are likely to mirror internal
dynamics.
• The concept of holding and making it safe
a la Winnicott
The treatment and its techniques
• Focus on therapist’s counter transference
i.e. their emotional reaction to the client.
• Therapeutic errors are inevitable.
Lurching from one therapeutic error to
another.
The treatment and its techniques
• Active neutrality and the concept of
multiple empathy. In other words finding
statements that allow empathy to both
sides of a conflict or to multiple voices
within the client.
Supervision and the supervisor
• It is amazing how little literature there is
too guide a supervisor in this type of
supervision. The move from practitioner
to supervisor is no less greater than what
the supervisees go through starting to
work in a dynamic model.
What is reflective supervision?
• Reflective supervision tends to focus away
from the client and onto the therapist and
their reactions and thoughts, feeling and
fantasies about their client.
• It is non-directive and uses Socratic
questioning in a more open ended way
rather than as guided discovery.
What is reflective supervision?
• There is a trust that the therapist has the
answers and it is supervisor’s role to assist
them to find them.
• The supervisors power comes from
providing a safe reflective space rather
than as an expert or someone with more
insight. The supervisor can be visualised
as a container for the therapists’ anxieties.
What is reflective supervision?
• Processing and voicing of emotional
reactions and when safe enough
exploration of the therapist fantasies in
regard this.
• Doing this, until a new place of empathy is
reached.
• Relating all of this back to the client.
What is reflective supervision?
• Reflective practice however at the end of
the day has to have a purpose.
What is reflective supervision?
• As good as a good bitch about a client
feels if this information is not utilised to
change what is happening in therapy then
it does not have real value.
• All this humanness, political incorrectness,
humour at the expense of the client still
has to be translated into a psychological
formulation about the client.
What is reflective supervision?
• Reflective supervision starts with where
the therapist “really is” not where they
“should be”.
What is reflective supervision?
• My own influences on this have been primarily:
• Fawley O’Dea and Sarnat’s book. The
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Supervisory Relationship which builds a
reflective supervisory model based around
Stephen Mitchell’s relational model (an extension
of object relations).
Susan Gill’s book: The Supervisory Alliance
What does this type of supervision
require
• Supervision needs to becomes a mirror for
therapy and vice versa.
• The need for safety and boundaries. This
needs to be made overt but must be
demonstrated by the actions of the
supervisor.
What does this type of supervision
require
• The need for neutrality and empathy to
the therapist’s internal states and needs.
• It is the supervisees job to do the work
the supervisor’s job to make the space for
that to happen hence the concept of
laziness.
• If the supervisor is working then the
supervisee is not working.
The need for the supervisors to reflect
on own needs
• How does our own narcissism, need for
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attention and praise interfere with encouraging
reflection.
How to balance our needs for this with best
interests of the student.
Understanding our own needs as supervisors
Understanding our driving schemas/conflicts
Managing our own sense of incompetence
Envy
Anxiety about intern incompetence reflecting on
our competence/value/esteem
De-idealisation of the supervisor
• It suits the supervisee as much as the
supervisor for the supervisor to be the
expert. This minimises anxiety and
defends against a sense of incompetence
on both sides.
De-idealisation of the supervisor
Interns come with highly idealised view of
myself due to:
• Previous interns
• Reputation
• Own insecurities (deskilling) about both
the complexity of the client group and
shift to a new type of therapy.
• I am an older male
De-idealisation of the supervisor
• Delicate balance of supporting and
informing at the same time gradually deidealising myself. Recognition of one’s
own narcissistic pleasure in this position
and trading this for vicarious pride in
interns achievements.
Use of self disclosure
Self disclosure is usually more common in supervision and
it can serve a vital function in helping humanise and deidealise the supervisor.
• Own emotional reactions
• Human and often politically incorrect reactions
• Use of humour
• Sharing of own weaknesses and examples of
therapeutic error s from my own therapy
• Own up to my own confusion and unsureness
• Enabling the sitting with ambivalence and unsureness
Counter transference and its reflection
• I want to spend the rest of the time
looking at one particular aspect of
reflective process and providing a vignette
on its use
Counter transference and its reflection
• Counter transference is defined in its
widest sense as whatever the therapist
feels or fantasises about the client without
implying anything about the origins of
those feelings. (Racker 1957, Hunt 2001)
Counter transference and its reflection
• Many supervisors are reluctant to explore
therapist’s reactions to clients. This is often on
the basis that it may intrude into the personality
and inner life of the intern-therapist or may turn
into psychotherapy..
• It is easy to justify that supervision should focus
on the client and technique and that CT is more
related to the therapist own “stuff”.
Counter transference and its reflection
• Nothing in my view particularly in the
treatment of BPD could be further from
the case and this focus on CT using
reflective techniques has become the
central part of my supervisory work with
Dpsych interns on our program.
Counter transference and its reflection
One can see that yes you can explore this
on a personal level:
• What memories does this stir up
• What underlying needs does this
interaction activate in the therapist
• What does this reflect about the therapist
life now and in his past.
Counter transference and its reflection
However this can also be explored with a view to reflecting
on what is happening with the client.
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What emotions did the client evoke in the therapist
What are the clients motive for evoking these emotions
What does this say about the therapeutic relationship
What might this tell us about the patients history
What might this tell us about the patients interaction
with significant others
What might this tell us about the client internal dynamics
Counter transference and its reflection
• This is the primary focus of using
reflective techniques in supervision. If the
therapist also learns something about
himself then this is a bonus but not the
primary focus.
• If nothing else this processing of
emotional reactions clears the therapist
head to think more clearly about his work
with the client.
Counter transference and its reflection
• This process can only occur in a relationship that
feels safe enough to the therapist.
• Intern therapists often carry a particularly rigid
and Jehovian idealised internal therapist and
emotional reactions, impure thoughts, and
politically incorrect characterisations are judged
harshly frequently evoking enormous amounts of
guilt.
Counter transference and its reflection
• As a result the therapist frequently
attempts to find an explanation within
themselves or within their own life. Far
easier to manage the guilt if it is my own
fault.
Counter transference and its reflection
• I call this the hypothesis of last resort.
The rule in our supervision is that one can
only blame oneself for what has
happened in therapy after we have
explored the view that it is the patient’s
fault. After we have blamed the client and
developed hypotheses around this.
Counter transference and its reflection
• This also demands that the supervisor put away
their anxiety and their fears that the therapist
may act on some of their emotions.
• Accepting more importantly a curious attitude to
all any reactions that come up is part of the
process of making it safe enough for the
therapist to explore these reactions
Counter transference and its reflection
• If the supervisor doesn’t pay attention
with this attitude, he communicates a
message that this is not to be talked
about.
• If the therapist is feeling guilty about it
may lead to some type of mistrust or
resentment directed toward the supervisor
and lessen the sense of safety.
Counter transference and its reflection
• The supervisor also has CT reactions to
the therapist and these also should be
food for discussion.
• The sharing of the supervisors CTs can
significantly deepen the supervisory
relationship. The therapist can see the
supervisor as human, fallible, unsure.
Counter transference and its reflection
• The interactions between therapist and
client and therapist and supervisor all
become useful grist for the mill to
hypothesise about what is going for the
client.
Counter transference and its reflection
• At a basic level simple assumptions are
made
• The interactions between client/therapist
and therapist/supervisor directly reflect
the clients relationships with significant
others both in their present and past and
should be explored as such (aka Malan’s
triangle).
Counter transference and its reflection
• More importantly we hypothesise that these
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interactions reflect internal interactions between
different aspects/modes/objects/selfs with in the
self.
For the therapist the processing of this counter
transference moves them from an emotional
position often accompanied by helplessness and
guilt to a position of understanding and
deepened empathy for the client.
Counter transference and its reflection
• This can then be taken back to the
therapy room and tested out and explored
with the client.
Symmetrical and asymmetrical parallel processes
Patient
Helpless, whining, victim
Therapist
Supervisor
Frustration, anger,
Frustration, anger,
directive
directive, controlling
Helpless (Neil Young
Helpless
Helpless
Aggressive attacking
sadistic
Defended angry
Directive and controlling
attacking back, guilt
and critical
triad) Incompetent
Symmetrical and asymmetrical parallel
processes
Patient
Therapist
Supervisor
Aggressive attacking
sadistic
Frightened, closing down Aggressive attacking
sadistic
Disconnected,
dissociated
Overactive intrusive
Angry or critical
Dissociated or defended
Bored, unable to recall
session
Bored sleepy